21970 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bunding Buildingemi(Imtlan PENMIrNO.
21970
cera sin/e: . one:
G/[... CITY OF CUPERTINO-BUILDING DIVISION
aachs, ne: L� uc.Na: APPLICATION I PERMIT — Z�
BUILDINGELECIRICALPLUMBINGMECEIAMCAL CATEGORY CONTROL
AmAitect/Engfiner: LIs.No:
QTY ELECTRICPERMTF FEE BUILDING PERMITINFO
Address: PEMITISSUANCE Sz
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
thereby
affimthatlam Bcensed.M.rpr WmsofChapterg(mmmenc. APPLIANCES RESIDENTIAL JOB DFSCRB'FION
IngwlthSectbn700Wo(DlWdon3oflhe0ualneseandProfndonsCode,and my
license is In full force and rifest. PANELS .�..{ {� ��
License Class Lkas ak �(`C"
Date Contractor UP TO 200AMM
ARCHITECT 5 DECLARATION 201-IODO AMTS
ce Z I understand my plans @hall be used as public remrds. OVER 1000 AMPS SQ.rr.FLOOR AREA 5/SQ.FT.
Licensed Pr fenlovl SIGNS ELECTRICAL
H OWNER-BUILDER DECLARATION SPECIALCILCIRT/MISCIL
ZE, Iherebyaffirmthatlamexemptfrmnthe Contr.aoro Li mine Lawfmthe
QQ following reason.(Seaton 7031.5,Business and Profenions Cade:Any city or
Fa' muntywhichrequlresapermitWmmtmd,alter,lmpmvgdemolbh,orrepalr TEA'.METER OR POLE INST.
SE anytru=ture prbrta lb Issuance,also requlrcslheapplicant forsuch permit to
P O file a signed statement that he in Imnsed pursuant to the provisions of the POWER DEVICES
flail m0� Contractor.License Law(Chapter I(coeumncing with Section 7glWo(Dlvl- SW13,MNG POOL ELECTRIC
,e sion3ofthe Buelas.and Profenbns Code)orthat he Isexemptiherefromand VALUATIQf}!,
6, the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWTTCHESEXTURES
applicant fora perenit subjects theappllcanttoa civil penalty of not morcthan
five hundred dollars CBS=. Lfael
I,as owmr of the roe NEW RESIDENTIAL ELFLTR SQFf. STORIES TYPE CONSTRUCTION
�2 p p rty,or my employees with wages as their sole
meopenstion,will do the work,and the structure Isnot Intended or offered for
O• vole(Sea 7DK Buelnevs and Professions Code:The Contractors Lim.Law
does net apply to an owner of property who builds or imprevea thereon,and OCC.GROUP RES.UNITS
who donsuch work himself orthrough Maown employees,provided that such ,
Improvementsarc not intended oroffered forsala.If,however,thebullding or TOTAL:
Improvement bsold w thnoneyearofcompletbn,lheowner-bullderwlll have
tilOkurden of proving the he did runt build or improve for purpose ofsle.). QTy, PLUMBING PERMIT FEE FLOOD TONE - APN
Lj L as owner of the property,am exclusively contracting with licensed pppMfl ISgUANCE
cer same to construct the project(Sec 7061,Business and Profesbm Code: UD
Contractors License Law does e apply to an owner of property who ALTER-DRAIN kVENT-WATER(FN
builds or Improves thence,and who contracts fee such p(ojects with a FEE SUMMARY
�attor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec B k P C for this recon
OUTSIDEFFrS
DRAINS FLOOR ROOF,AREA,COND. a- SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FD'nM2LPFR TRAP SCHOOL TAX Y N
QT teof affirm that I have• lmunne of consent to pytheare,ora O O RECEIPT M
.sJ m00,LaeofWorkers CempensaHanlnsunnmmamrtifled mpythereof(Sec. GAS E.A. YSTEM-1 INCA OLMXTS PARK FEE Y N
Policy N CJ - RECEErT M
Palley N
y GAS P.A.SYSfaf-OVER d(EA) BUILDING DIVISION FE ES
Certified copy Is hereby furnished.
CofGREASE/INDIISIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE Of DOWIPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-b10RM EA POET Date Recei Tri
(TMaeectbn need sea becompleted tithe permit Is forom hundred dollars
Mae)or len.) WATER HEATER W/VENT/ELKTR ENERGY FEE Y N
I certifythat In the performance of the work brwhich this permit is Issued,
I shag nm employ any person In any manner so s to become subject to the WATER SYSTEM/TREATING
n'
WwkeCompensation laws of California.Date PAID '
O Q Applicant NEWRESIDENTIALPLMB. SOFT. Date Recef til
Z NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you neat forthwith comply with such provbioru or this permit shall be
> deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffimn that them b a corutruction Imclingagency for the perform _d ELECTRIC FEE
n Z anmaf the workfor which this permit Is baued(Sec.3097,CIv.C.) TOTAL: (>�
00 Lenders Name PLUMBING FEE
LL h- Lenderb Adders• QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ImrtifythatlMvercadthIs.pplimtbnandstatethattheabovelnfomutlon
a Ismrrect.f agresto comply withaR cityaol county ordinances and gate laws PERMITISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorise representative.ofthis
cit to net., awmentiumd propertyfor inspection ALTER OR ADD TO MECH.
F 2 y pO ha he p"rpOBCB' Date Recei til
o sve,la ty an d keep harMem the City of Cupertino P
V that, ,dud ,co.t•ande lossax which may In anyway accrue AIR HANDLING UNIT(TO10,000CFM) SUBTOTAL:
a t I win of the granting @t his permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gna rat retractor Date ) E(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wilit eappHantmfuWmbulldingoccupantstamorhandleha rdoua HEATING UNIT(TO 100,000 BTU) Date Recel tp
malaria as defined by the Cupertino Municipal Code,Chapter 912,and the
Health and Safety Code Seaton 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: a_
Yen _ MN. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Ilethe appllcousgr4ontandlding as defined
ndby the Bay Anna
it ��g,�
whichemithagemnt District? antsae defined by the Bay Area Alr
Quality Management District? BOILER-COMP QEIPDR 100,fXD BTU)
4 Yes No
have read the ue teciabrequlremenlsunder Chapte,6.95of BOILER-COMP(OVEt 100,000 BTU) 1a 9
the Caltiomla Hea k ( ode,SMlons 25505,75533 and 25531.1 I •r'>t'I� v �`
and od tha thp� gdue.nm currently have a tenant,that It Is my NEWRESIDFNTIALMECH. SQ.FT.
ne I a pant of the requlremenb which musthemet
o teofOccupancy. 01
�rlj�ltk�J `1
Own an, Date ISSUEDBY: AtZQ1 s'l.✓' 'lk
TOTAL:
OFFICE COPY